I did another 36 hour shift today. I can easily say it was one of my worst shifts - not because of anything my preceptor or I did, just the nature of the calls I ran - two specifically.

The first one was an 83 year old lady who was having heart palpitations, weakness, numbness, etc - and thought she was having a stroke. We put her on the monitor and she's in a pretty clear a-fib with a rapid ventricular response. She said she had a pacemaker, but it wasn't showing up on the EKG. We load her up into the ambulance and all of a sudden her pacemaker kicks in and her heart rate jumps into the 120's. Now that its a paced rhythm, I can't give her Cardizem. Everything was going okay until she started to pray in the back of the ambulance and whisper "It's getting nearer, I can see him." She hadn't had any altered mental status before. When someone starts praying and seeing things in the back of your ambulance, you know that something is going to happen. I turned to the attendant and told her to step it up a bit. It turned out okay, she made it to the hospital and into the ICU. They put her on coumadin for her a-fib, so I'm assuming she's okay.

We ran a few more calls - a lady face planted into the cement walkway at a local home improvement store and had a nice hematoma and laceration on her eye... stuff like that.

Apparently it was trauma day for the 12 hour shift I pulled. We get toned out for a second-line ambulance for an MVC in east county - one of the more rural areas. There's a confirmed 10-79 (dead body) on scene and one victim. They asked for a chopper to land on the highway, but none were available. We roll up on scene right behind a supervisor. Some bystanders are untangling the two people - one is clearly dead and the other is whimpering. We get her into the back of the ambulance and RSI her. When I placed the OPA in her mouth to open her airway, the top of her teeth and jaw move left, right - back and forth. SHe's got what we call a LaForte II fracture (II since it's up into the zygomatic bones). They RSI her and we get out of the ambulance since they have to get going.

We're heading over toward the DB when one of the bystanders runs over screaming "A guy just drove down the road and was ejected! You guys need to get over there!" Goodie. We hop into the ambulance and drive about 300 yards down the road and sure enough, there's a motorcycle laying on the street with a bunch of people surrounding an 50'ish year old guy laying on the ground. I look at my preceptor to double check his "You're running the calls from now until you leave" rule is still in effect. He nods and I head over. I give him a quick once over - his left leg is sticking out at a 90 degree angle from his body and he's got an open femur fracture and a completely fractured right radius - I know that for a fact because the end of the radius was poking out the side of his forearm. A firefighter is sitting there and I bag him a couple of times and check for a pulse. I don't find any, so I tell the firefighter to start CPR while I get the pads put on. The stupid idiot checks while the EMT is bagging and says he feels a pulse. I tell him that no, there is no pulse - please start CPR.

This guy is a mess - we can't get a line by IV, so my preceptor breaks out the IO. Because of his bilateral femur fractures (I find that on a rapid) we had to go in through the head of the humerous. This guy is pretty hefty, so it barely goes in.... then one of the firefighters strapping him to the board yanks out the IO - our only line.

I make one attempt to intubate before I have him moved to the ambulance, but he's got no neck and has vomited. We don't have suction nearby so I scoop out some of it with my fingers and tell them to keep bagging him.

Anyway... we're in the back of the ambulance and I can't intubate... I got nothing. My preceptor makes the attempt while I concentrate on getting meds on board (since the firefighters were Basics and less than useless except for doing compressions). My preceptor finally says "Fuck it" and gets a CombiTube - it's a blind insertion. We finally get an airway and I shove some epi down the tube. We keep CPR going and I shove some atropine - he's gone from a pulseless electrical rhythm to complete asystole. I know what has happened and that it isn't going to end well, but we have to keep going. My preceptor reminds me that their protocols allow for prophylactic decompression. I do a quick exam and hear breath sounds, but his right chest is pretty flat. I tell him to give me the needle and I shove it between his 2nd and 3rd rib. Whew, done.

By now w'ere at the hospital, we pull get him out and his leg flops open when they move him to the trauma bed. This is the bad thing. Apparently when he flipped OVER his motorcyle, he did the splits over the guard rail. He was completely split up the perineum. He was not only bleeding from a femoral artery split on one side (and dumping into his leg on the other) but he had also bled out from the middle. He was completely exanguinated. I realized early on that there was nothing I could do - nothing even the best paramedic could do. He had bled out inside his pants and they were hiding quite a bit of blood - as was his abdomen. Even if we had ten lines, all we'd be doing is replacing his blood volume with salt water. Even in the hospital, once they started giving him blood he started to leak it all out again. It was just a bad call altogether. A bad day, to be sure. It would have been nice, too, if his wife not come up while we were on scene.

Whelp, I need to get to bed. I have another 24 hour shift tomorrow. I miss everyone, and thanks for listening to the gruesome details of my day, even though I did leave some details out.